What is stress?

Stress is a physiologic state of mental or emotional strain resulting from some form of adverse or demanding circumstance. Stress can be triggered by many things that are real or perceived and can be experienced in variable degrees in different individuals.

How can stress affect your health?

It is important to remember, that not all stress is bad. It is a natural physiologic response that can be life-saving in some situations such as escaping a burning building. During a stressful situation, your body releases particular compounds and hormones that heighten your senses, tense your muscles and increase your heart and lung function to get you ready to run. In short bursts it is a blessing; however, with chronic stress, the prolonged and continuous exposure of your body tissues to these compounds is detrimental to your health. The stress response boosts certain organ systems such as your heart, lungs and muscles which are immediately needed for survival over others such as your immune, digestive and reproductive systems. As a result, their activity is limited and impaired. Once the threat has passed, these other body systems restore themselves. If they are unable to do so or if stress remains chronic, serious health problems can develop including stomach ulcers, heart disease, high blood pressure, diabetes, depression and anxiety and in rare cases, death.

What are common stress-related symptoms?

Everyone feels and responds to stress in different ways. Some individuals predominately experience digestive symptoms, whereas others may develop sleeplessness, headaches, depressed mood, anger or irritability. Because chronic stress can impair the immune system, there is an increased propensity for more frequent and severe infections, including the common cold or flu.

How can I decrease and better cope with stress in my life?

It is never too late to start taking steps towards maintaining your health and outlook which can reduce or prevent the ill-effects of chronic stress. Some tips include:

Surround yourself with positive people and those who can provide emotional and other support.

Set priorities and decide what must be get done first, what can wait and learn to say no to new tasks if they are putting an excess load on you.

Review your accomplishments at the end of the day and not what you have been unable to do.

Limit your focus on problems.

Schedule healthy and relaxing activities such as spending time with loved ones or doing your favorite hobby.

Exercise regularly as even just 20-30 minutes of mild-moderate exercise can help boost your mood.

What is sleep?

Sleep is a naturally recurring state characterized by altered consciousness, muscle and sensory activity and waste removal. It is a time of complex neurobiological rejuvenation and growth and appears to be universally vital to life throughout the animal kingdom.

What is the role of sleep and why is it so important?

We spend about one third of our lives sleeping and despite our limited understanding of the purpose and mechanism of sleep, we know that like food, water and oxygen, it is critical for life. Sleep plays a vital role in many body functions including immune regulation, metabolism, tissue repair (release of human growth hormone (HGH)), learning and memory.

How much sleep do I need per night?

The duration of time needed for sleep changes as you age. Infants and adolescents need more sleep to fuel their growth. As you age you may find that you need less and less sleep. Rather than focus on the number of hours spent sleeping, you really should ask yourself if you feel well rested on awakening? If not, you did not get enough sleep. Although we progress through different phases of sleep during the night, it is the deepest stage of non-REM sleep where your body does most of its housekeeping. Recent research has found that the brain clears away waste products at night, which suggests that poor sleep may increase your risk of dementia (Xie, L. et. al 2014). Generally, most adults feel their best with an uninterrupted 7-9 hours of sleep. Most Americans do not get enough sleep according to the CDC (Liu et. al. 2016).

How can I improve my sleep?

If you can improve your sleep, this is one of the best things you can do for your health. Do not get frustrated by the process. Instead, let it come naturally and keep it simple by trying these easy ideas. Remember, you need to train your body to sleep well. You can also use a sleep tracker to keep track of your progress.

Sleep Hygiene

Ideas

Habits

Develop a bedtime ritual. Consider taking a warm, calming bath.

Bedroom

Sleep in a cool and dark room away from noise and distractions.
Get comfortable by using pillows to support body and wear non-restrictive pajamas.

Diet

Avoid caffeine, sugar. artificial sweeteners and flour as they can be stimulating.
Limit fluid intake several hours before bedtime and empty your bladder prior to bed to minimize night-time bathroom trips.

Exercise

Exercise daily.
Do not exercise at night as it can keep you awake.

Home Remedies

Lavender essential oil (a few sprays under pillow or drop of oil on the upper lip)
Melatonin
Review the day with your loved one.

What is an anti-inflammatory diet?

An anti-inflammatory diet is one in which fresh fruits, vegetables, meat and seafood are eaten with little or no intake of processed foods. The purpose of this style of eating is to eat foods that are high in vitamins and minerals along with healthy proteins and fats to support the growth and repair of your body. These foods also tend to be lower in calories than processed foods.

Why is an anti-inflammatory diet important?

Now more than ever, our society is plagued by a wide variety of chronic diseases. And while it may not be accepted by mainstream society, it has everything to do with your diet. Scientific research and clinical experience have shown that dietary modifications and administration of nutrients and other natural substances are frequently and almost consistently effective for both preventing and treating a wide range of symptoms and illnesses.

Over the past several generations, we have established a new standard diet of highly processed foods that are high in sugar and fat and low in fiber. Furthermore, modern farming techniques are designed to produce high crop yields at the expense of low nutrient density. As a result, we consume more calories with fewer vitamins and micronutrients than our ancestors did. Many experts believe this is a major cause of chronic diseases such as heart disease, cancer and chronic pain.

Doctors that emphasize different styles of anti-inflammatory diets

Why is sugar such a problem?

The average American consumes 44 teaspoons of sugar per day. Sugar is used to mask inferior ingredients in products, improve flavor, and has over 50 different aliases in the list of ingredients such as high-fructose corn syrup, dextrose, rice syrup, mannitol and evaporated cane juice. Sugar is one of the most dangerous and addictive substances in our diet. Research studies have shown sugar to be more addictive than alcohol, cocaine and even heroin. Artificial sweeteners such as Aspartame (NutraSweet®) breakdown to components that are known to be neurotoxic. We all know that excessive sugar consumption contributes to obesity and tooth decay but it also contributes to the development of other symptoms and diseases including chronic pain, fatigue, anxiety, migraine headaches, high cholesterol, liver disease, osteoporosis, hypertension, diabetes mellitus, cancer and heart disease.

What is wrong with bread?

We cannot tell you how often we hear our patients tell us, “I love bread and I can’t live without it” and we understand, as it is a staple in cuisines around the world. Over the past 50 years however, wheat has undergone a dramatic and drastic makeover. Hybridization and genetic manipulation by agricultural scientists focused on increasing yield have turned modern wheat into a distant relative of the grain our ancestors once consumed. The current strains of wheat that are available today are so unique that they are unable to survive in the wild without human support and many scientists also believe that wheat has begun to interfere with our immune systems.

The nutrient-rich germ portion and the nutrient and fiber-rich bran portion of grain is removed during the milling process. As a result, ingesting these processed grains impairs your body’s ability to control blood sugar. Flour contains substantially lower amounts of vitamins, minerals, and fiber than in the past. Your body treats the small flour molecules like sugar with the same risk of developing the diseases mentioned earlier. This is independent of the gluten molecule that many people with celiac disease are allergic to, which creates its own havoc within the gastrointestinal system.

Extruded grains such as breakfast cereal, as well as puffed wheat, puffed oats and puffed rice are processed using high heat and pressure which makes them virtually indigestible. This creates a food that is even worse for your body than sugar. It is no wonder that breakfast cereals are fortified with vitamins and minerals.

Sprouted whole grains, however, unlock the essential vitamins and nutrients that are naturally present within the grain. Sprouting neutralizes phytic acid, which is known to block the absorption of nutrients by the intestinal track, as well as a number of other enzyme inhibitors making this form of grain more nutritious.

The bread detective

Does milk really do a body good?

Research has demonstrated that cow’s milk is one of the most common food allergens in the American diet. From an evolutionary perspective, your body may be able to digest milk, but pasteurized and homogenized milk as well as the various low-fat and non-fat milk products involve a great deal of processing, which ultimately makes them more difficult to digest. Recent research has demonstrated that milk does not offer any nutrients including calcium, proteins and fats that cannot be found in other healthier animal or whole plant foods. Contrary to popular belief:

-You can get much more vitamin D from just a few minutes of direct sun exposure than from milk. Research suggests vitamin D is more important than calcium for bone health.

-Milk products have never been shown to reduce fracture risk and may also increase your risk of death due to the high quantity of natural sugar (lactose) found in milk (Michaëlsson K et. al 2014).

If I keep eating these foods, what can happen?

The side effects of a nutrient-deficient diet are more profound than you have probably ever imagined. Foods that are unhealthy are the exact ones that are subsidized by the government, so they are made more affordable, which promotes a vicious cycle of greater consumption and illness. Consuming disease-promoting, nutrient-deficient foods over decades not only reduces your intake of vital nutrients, but also increases the burden on your body, speeding up the depletion of nutrients from your body. A new field of nutritional genomics is beginning to unlock the secrets of the effects of food and nutrition on your DNA. Scientists can now study how food and nutrients change the way your cells use your DNA code and the proteins made from it. If the cells are not working optimally, this sets the stage for a variety of illnesses mentioned previously, as well as mitochondrial dysfunction believed to be involved in the onset of cancer, inflammatory and autoimmune diseases. It is not a question of if, but rather when a disease will interrupt your busy lifestyle.

What are some easy things I can do to improve my diet?

You can start by eliminating or significantly reducing your daily intake of sugar, flour and dairy products and increasing your intake of fresh, local vegetables and healthy proteins every day. Michael Pollan, a journalist and the author of numerous books on food including, “The Omnivore’s Dilemma” and “In Defense of Food,” believes you should eat local food closest to its natural state. While changing one’s dietary habits is no easy task, you will begin to see changes within three to six months. Our patients have reported improved sleep, greater energy and focus, as well as improved vision, stronger hair and nails, and better looking skin. We are especially excited to hear patients report that they have discontinued blood pressure, cholesterol, diabetes, anti-depressant and reflux medications as a result of these dietary changes. Once you start feeling better it is very hard to return to your old diet.

Ideas for Promoting an Anti-inflammatory Diet

Type of Food

Nutrient Value

Recommendations

Vegetables and Fruit

Protein from grass-fed, hormone-free, antibiotic-free and non-GMO sources are ideal and are good sources of protein as well as omega-3 fatty acids and other nutrients.

Eat sprouted whole grains that have not been highly processed such as bulgar, spelt, kamut, buckwheat, oats, farro and brown rice.

Dairy

Dairy can be a rich source of nutrients.

Grass-fed butter, cheese, yoghurt and other whole milk products are very healthy.
Consider sheep or goat milk products over cow milk if available.
Remove or limit consumption of pasteurized and homogenized milk in addition to skim, low-fat and non-fat milk, cheese and yoghurt products.

Sugar

No nutritional value

Reduce or eliminate intake of all sugar products including cereal, granola and energy bars, fruit yoghurt and candy.
Avoid high-fructose corn syrup.
Remove artificial sweeteners as they are more toxic than sugar.

Oils

Good source of important fatty acids

Extra virgin olive oil is safe to use in it’s natural state on salads or in low heat applications.
Coconut oil is better suited for high heat applications.
Remove all vegetable oils and canola oil as their production makes them pro-inflammatory.

Beverages

Essential for keeping hydrated, flushing out toxins from your body and can be a source of antioxidants

Replace regular and diet soda, fruit juices and sugary iced tea with water, lemon water or dilute tea.
Drink more tea and less coffee as it has lower levels of caffeine and is a great source of antioxidants.

To get you started with your new dietary habits, make sure you include proteins, healthy fats, vegetables and fruits with each meal to feel satiated.

What to do NOW to improve your diet

Eat a colorful variety of local vegetables more often than fruits.

Get to know the vendors at the local farmer’s market and buy foods that are in season to maximize their nutrient content.

How can exercise improve my health?

If exercise was a pill it would be a guaranteed best seller with few side effects. We know that exercise has multiple health benefits and plays an important role in successful aging. Some of the many benefits of exercise are that it will:

How much exercise do I need?

Aim for at least 2.5 hours of moderate exercise (where you can talk but do not have the breath to sing) per week. This translates into about 20-30 minutes, 5-7 days per week. Be sure to incorporate interval training which stresses and hence builds muscles more effectively. Always start slow and gradually build up your exercise routine to minimize the risk of injury. If you are older or have a serious medical condition, remember to consult your physician before starting any exercise regimen.

What is the least amount of exercise I can do to get significant health benefits?

The amount of exercise you need for health benefits is much less than you may think. A large study on exercise and mortality found something researchers did not expect, that running for as little as five minutes a day could significantly lower your risk of premature death (Lee D.C. et. al., 2014). So no matter how busy you are, we are sure you can fit in five minutes a day of vigorous exercise, such as running, jump-roping or pedaling vigorously on a stationary bike. Consider simple things in your daily routine such as running for the bus or walking up several flights of stairs while at work. Over the long-term even brief amounts of exercise may add years to your life.

A single session of simple static stretching can result in short-term cardiovascular benefits as well. When you stretch, your brain releases compounds that not only relax your skeletal muscles but also relax the small muscles in the walls of your blood vessels (Farinatti et al., 2011). This results in their dilation, which can lower your blood pressure.

#1 Regenerative injection therapy (RIT) has been in clinical use for over a century.

A form of regenerative injection therapy was used as a hernia treatment in the early 19th century by Dr. Jaynes in Louisiana (Rice, 1936). In the 1950s, George S. Hackett M.D. developed a form of regenerative injection therapy that he termed “prolotherapy”. He found it very successful for the treatment of ligament laxity leading to other musculoskeletal conditions (Hackett, 2008). His focus was on injuries of the tendon as it inserted into the bone (enthesis) and of ligaments that inserted into the bone (fibro-osseous junction) (Zone 3 in the figure below).

The bone tendon and ligament junction is the most common site of injury due to the significant differences in material characteristics between solid bony tissue and flexible tendon/ligament tissues.

#2 Regenerative injection therapy heals injuries that lead to arthritis later in life.

With advances in technology, there has also been a great deal of research done on joint and cartilage injuries. Regenerative solutions have been used to begin the regeneration of tissues. These solutions include hyperosmolar dextrose or mannitol, platelet-derived growth factors and mesenchymal stem cells (Hauser, 2014; DeChellis, 2011). Once injected, these solutions restart your body’s natural healing cascade which promotes the growth of normal cells and tissues.

Regenerative injection therapy is often done with one or more treatment sessions (Distel, 2011; Rabago, 2010; 2013). The end point of treatment is the elimination of joint instability, progressive joint degeneration and pain. Clinically it has been observed that once joint stability is restored, pain and muscle spasms resolve with a return of normal functional biomechanics.

#3 Identifying the source of pain can speed up treatment.

Fluoroscopic or ultrasound-guidance can be used to identify the precise tissue defect that is the source of the pain. Tissue defects can be found even if x-rays and MRIs are absolutely normal. If accurate anatomic localization is difficult, several sessions are usually needed to identify the precise pain generator.

#4 Regenerative injection therapy can treat many chronic and difficult to treat injuries.

Excessive popping or cracking of the spine or joints (joint instability)

#5 Regenerative injection therapy repairs tissues.

Regenerative injection therapy is the only treatment available for the repair of ligament and tendon injuries (Anitua, 2004;Krampera, 2006; Lam, 2003; Liu, 1983; Reeves, 1995). This reverses the abnormal stress on the joint that can lead to future osteoarthritis and pain.

#6 Regenerative injection therapy is successful even if surgery fails

Regenerative injection therapy can also be used if extensive surgery, such as rotator cuff repair, ACL repair, or joint replacement surgery have not been completely successful.

#7 Regenerative injection therapy can work many years after an injury or accident.

Bracing, physical therapy, kinesio taping, and activity modifications can also be helpful, but they do not heal long damaged tissues. Oral medications and corticosteroid injections inhibit or delay the healing cascade which helps with pain but do not heal the underlying tissue injury.

These are the most important back exercises that you can do for your back to maintain flexibility and strength. If any of these exercises cause pain, you should stop the exercise and see your doctor who may do a further workup which may include an MRI. These exercises will not help if you sit for long periods of time.

In sports medicine, physicians focus on cartilage, discs and nerves, but we rarely talk about ligaments which keep your bones together, except when it comes to a knee injury. Once a ligament is injured, the structure it holds together tightly becomes loose. With loosening, abnormal motion develops in the joint resulting in occasional pain and a progression to osteoarthritis many years later. With the huge number of musculoskeletal injuries that are treated yearly in the U.S., we need to think more holistically about joint injuries. Unfortunately, those injuries that physicians do not treat properly, results in another joint replacement or an additional member of the millions of Americans who are permanently disabled. In my practice, I have been able to treat injuries, even many years later, when I include ligaments in the treatment plan.

Ligaments are amazing structures, and if you know a little about them, you will able to keep them healthy and live pain-free.

Musculoskeletal disorders are the most frequent type of chronic pain condition (Murray CJL, 2012; United States Bone and Joint Initiative, 2014), and is a leading cause of disability in the United States affecting almost 160 million people (IOM, 2011). This type of pain develops when local nociceptors detect chemicals released from damaged tissues such as of the joint capsule, tendons, ligaments and fascia. Nociceptors are free nerve endings that originate in the dorsal root ganglia that release a number of substances including calcitonin gene-related peptide (CGRP) and substance P. These substances are known to cause cellular changes in nerves that result in local tissue sensitization as well as modify central pain pathways (Sanchi-Alfonso V 2000; Seybold VS, 2009). There are many pain generators within tissues, but it is thought that most of the pain associated with musculoskeletal injuries originates from the weakness or laxity within the enthesis of tendons and fibro-osseous junction of ligaments.

Ligaments are important because they:

guide forces through adjacent bones or joints

provide joint proprioception

provide mechanical feedback

provide joint stability by limiting excessive joint range of motion

The thick collagen bundles that make up ligaments are generally aligned along the long axis of the ligament, although not as completely as in a tendon. A ligament may appear as a single structure during joint movement, but at a microscopic level, fibers may tighten or loosen depending on their specific position and the overall force that is applied (Frank, 2004).

Unlike tendons that aligned in one direction, ligaments are aligned in a web to keep the joint stable in many different positions.

Each collagen bundle is made up of a collagen matrix with interspersed fibroblasts which are responsible for collagen synthesis and repair (Frank, 2004). Two-thirds of the ligament weight is water which provides its characteristic viscoelastic properties. The remaining 1/3 is a mixture of collagen (85% of which is type I), glycoproteins, elastin and proteoglycans (Frank, 2004).

Components of a ligament

At the molecular level, collagen is synthesized as procollagen molecules that are secreted into the extracellular space, then the helical collagen molecules line up to form fibrils and subsequently collagen fibers that make up the ligament. An enzyme called lysyl oxidase promotes the placement of crosslinks within and between the collagen molecules. This crosslinking creates the tremendous characteristic strength of ligamentous structures (Frank, 2004).

Ligament anchor in the bone

Direct bonding among structurally different materials can be challenging and the body gets around this problem by using a sequential arrangement of tendon or ligament, fibrocartilage, and mineralized fibrocartilage (Sharpey’s fibers) that insert perpendicularly into the bone at the junction. There is significant force that is transmitted through this area so injury and tissue damage most often occur at this junction.

Fibroblasts repair and maintain tissues

Fibroblasts are responsible for matrix synthesis and repair and appear isolated and interspersed throughout the ligament. They are thought to communicate via cytoplasmic extensions that may extend long distances resulting in a complex 3-dimensional structure (Benjamin, 2000; Lo, 2002). Gap junctions have also been detected within the cytoplasmic extensions suggesting a potential to coordinate tissue-wide cellular and metabolic responses (Frank, 2004). This gives fibroblasts the capacity to coordinate regional tissue repair.

2. Ligament biomechanics

Nonlinear behavior

Crimp

The microstructure of ligamentous structures are made up of collagen bundles aligned along the long axis of the ligament with a crimp or “waviness” along its length. Crimp is thought to play a specialized biomechanical role during loading, allowing the collagen fibers to straighten (uncrimp), so the ligament may elongate without tissue damage under a constant or cyclically repetitive load (Amiel, 1995). It results in a nonlinear elasticity, but with continued loading, a nearly linear stiffness develops until complete failure of the tissue.

Viscoelastic behavior

Viscoelasticity refers to the time dependent mechanical relationship between stress and strain that is not constant but dependent on the time of displacement or load. In other words, tissues are stiffer and stronger with high strain than with low strain. There are two major types of viscoelastic behavior, creep and stress relaxation.

Creep

Creep describes increasing deformation under constant load. This contrasts with elastic material which does not deform no matter how long the load is applied. If a ligament is placed under prolonged stress, within its load-bearing capacity (such as in prolonged slouching) then the creep will not immediately return to its pre-load form (loss of energy) because of a concept called hysteresis. Hysteresis describes how once a force is applied that has stretched the tissue and it is then removed, the tissue doesn’t return to its original length. This has to do with energy loss during the stretching process and the process of breaking bonds that had formed between the collagen (hysteresis may be temporary if bonds reconstitute). This process occurs with progressive stretching of tissues.

Stress relaxation

The second form of viscoelastic behavior is stress relaxation. This tissue characteristic describes how stress on a tissue will be reduced or the stress within the ligament will decrease under a constant deformation or strain.

3. Injury and repair of ligaments

Ligament healing occurs in three phases: bleeding/inflammation, cellular and matrix proliferation and remodeling with maturation.

Phase 1: Inflammatory phase

In the first phase, the ligament ends retract with the formation of a blood clot which is replaced with cellular infiltrate, with associated increased vascularity at the site.

Phase 2: Cellular and matrix proliferation

In the second proliferative phase, scar tissue is formed by hypertrophic fibroblastic cells. The scar tissue progresses after a few weeks from an initially disorganized structure to well aligned but smaller collagen fibers made up to more type III and type V collagen.

Phase 3: Tissue remodeling with maturation

The third and final phase of ligament healing is the process of remodeling and maturation. In this phase there is continued work on the altered collagen types, continuing collagen crosslinking, thickening and maturation of the collagen fibrils as well as improved cell connections and innervation. In this phase, the viscoelastic properties can recover to within 10-20% of normal, meaning that the healed ligament is less efficient in maintaining a load.

Ligament scars also demonstrate inferior creep properties. Complete ligament healing continues to be elusive (Frank, 2004), and the final overall strength of a ligament is also affected by its location, degrees of crimp, aging, pregnancy, diabetes, immobilization and use of NSAIDs.

4. Repetitive ligament injuries (micro-trauma)

If the mechanical properties of the ligament are temporarily altered, it cannot sustain reapplied loads in the normal way, so it is prone to injury in a process called fatigue failure. Each subsequent application of force further weakens the tissue although the damage may not be apparent. With further repetitive activities, the weakness will accumulate and the tissue will eventually fail at a much lower load than what would be expected to result in injury. Repetitive physical activity and reloading of the ligament over prolonged periods without sufficient rest and recovery creates cumulative micro-trauma. This results in chronic inflammation that is associated with collagen matrix atrophy and degeneration creating a permanently damaged, weak and non-functional ligament (Leadbetter, 1990).

A silent chronic inflammation that in some cases may have been developing over many years appears one day as a permanent disability associated with pain, limited motion, weakness and other disorders (Safran, 1985).

A common analogy is metal fatigue and subsequent failure that occurs with repetitive bending of, for example, a paper clip. Bending a paper clip once will not result in metal failure, but with repetitive bending, the metal will fatigue and ultimately fail. This is why tissues fatigue and eventually fail without a history of obvious trauma. With a sprain injury or a partial rupture of the ligament, the healing process, may not result in full recovery of the functional properties of the tissue with up to 50-70% of the ligament’s original structural and functional characteristics restored (Andriacchi, 1956; Woo, 1980).

Chronic musculoskeletal pain is due to incomplete repair of fibrous connective tissue which results in ligament and tendon weakness or laxity.

When these damaged tissues are quickly loaded, mechanoreceptors are activated to protect the tissue resulting in pain (Leadbetter, 1994). Incomplete healing is common after a tendon or ligament injury (Browner, 1992). Even submaximal activities that are repetitive may also result in tissue damage, but may not be sufficient to stimulate a healing response so there is an accumulation of tissue overload and damage which is imperceptible until there is enough tissue damage and patients will describe a sudden onset of pain. The use of NSAIDs may also delay or even limit the healing response as well. Electron-microscope images of ligaments reveal that submaximal loading can disrupt some fibers. Some collagen fibers can lose their wavy appearance suggesting the development of a permanent deformation. This suggests that ligaments may continually experience microstructural damage as a result of strenuous activities. This results in overuse injuries as the tissues become further damaged and weakened, resulting in a chronic pain syndrome.

5. Effect of immobilization

With immobilization or reduced physical activity there is decreased overall collagen mass and metabolism, collagen fiber diameter, fibril density and fibril number (Amiel, 1983). Immobilization also results in increased osteoclastic activity with resorption of bone and disruption of the pattern of ligament fibers that insert into the bone (Woo, 1987). Yet with moderate repetitive ligament stimulation coupled more importantly with appropriate rest and recovery allows a tissue to increase its strength and thickness to protect joint stability in persons exposed to increased physical activity (Suominen, 1980). Studies have shown that a greater amount of time is needed to regain original strength than the original immobilization (Noyes FR, 1974). It is thought that regular exercise may retard age-related physiologic decline as much as 50 percent (Menard D, 1989).

6. Muscle spasms from ligament injuries

Muscles can also fatigue, but because of their contractile ability, they rarely fail. Muscle spasms occur when the joint capsule, ligament or intervertebral discs are damaged. Muscle spasms occur to brace and protect the damaged area but can also contribute to the symptoms of local pain and stiffness.

Muscle fatigue, which also results from sustained postures, such a prolonged slouched posture results from muscle overload. They are overloaded while trying to support a less than optimal upright position, the accumulation of metabolites and less than optimal blood flow or ischemia results in the perception of pain. The constant muscle contraction limits the free flow of blood through the muscle stimulating pain fibers. If you move and stretch, blood flow is improved and the muscle pain is reduced. Shortened and tight muscles can also restrict the joints leading to greater problems in the future such as osteoarthritis and injuries that do not heal.

7. Ligamentomuscular protective reflex

Tendons transmit muscle force to bone and dissipate energy where as ligaments augment joint stability and guide the direction and magnitude of joint motion. The free nerve endings present in ligament are thought to act as mechanoreceptors that detect joint position, speed, and movement (Akeson WH, 1984) and they are also thought to transmit nociceptive information as well (Panjabi, 1992). Hence, injury in one segment of the body may refer to distant body parts via the sensory nerve endings within ligaments (Rhalmi, 1993).

A reflex activation of muscles by stimulation of the ACL was first noted in 1987 and a ligamento-muscular protective reflex was then identified in most extremity joints (Solomonow, 1987; Solomonow, 2001). The reflex pathways communicate ligament strain to the central nervous system. If it is abnormal, it will then respond by stimulating specific muscles to contract to prevent further joint displacement or injury resulting in muscle spasms. Research has shown that full stabilization of the joint complex can resolve associated trigger points or muscle spasms (Dagenais, 2007; Jansen, 2008; Jensen, 2008; Rabago, 2013).

In the spine, strain of the passive system of the lumbar spine can excite the mechanoreceptors and lead to a reflexive contraction of the associated multifidus muscles (Solomonow, 2003; Williams, 2000). The primary initiator of a reflexive multifidus muscle contraction is strain of the zygapophyseal (facet) joint capsules during creep as the multifidus has been found to have direct insertions on the facet capsules (Little, 2005). This reflexive multifidus contraction has been observed up to three levels above and below the strained lumbar segment. It is thought to protect the spine by increasing stiffness and decreasing excessive displacement of the spinal segments (Solomonow, 2003). When the passive structures of the lumbar spine are subjected to a steady load, similar to slouching or repeated bending, creep develops in the viscoelastic structures. The laxity induced due by the creep phenomenon leads to desensitization of the mechanoreceptors in the viscoelastic structures of the spine (Sbriccoli, 2004; Solomonow, 1999, 2003). The reduction in the protective reflex of the lumbar extensor muscles has been shown to be directly due to the desensitization of the mechanoreceptors caused by laxity in the viscoelastic tissues and unlikely due to muscle fatigue (Solomonow, 1999). Creep within the ligamentous structures increases the laxity of the spine by a clinically undetectable amount desensitizing the mechanoreceptors and inhibiting their ability to monitor segmental motion (Solomonow, 1999). This hinders the reflexive muscular forces that are essential for segmental and overall spine stabilization (Solomonow, 1999). It is thought that increasing ligament laxity in the spine increases the risk of disc degeneration (Acaroglu, 1995)

The effects of prolong (50-minute) static flexion of the lumbar spine was done in an animal study (Williams, 2000). Multifidus EMG activity was present upon initial stress of the supraspinous ligament, but the EMG activity gradually decreased in the first 3 minutes as relaxation occurred within the viscoelastic structures. Following 10-50 minutes of static physiologic loading, multifidus, spinalis and longissimus EMG activity was demonstrated, which corresponds to muscle spasms (Williams, 2000). This study suggests that accumulated submaximal stress of passive tissues may eventually result in damage with reflexive spasms and pain (Adams, 1996). In vivo studies have demonstrated increased muscle tension with two hours of sitting which increases the overall muscle tension within the lumbar spine in addition to the loss of the reflexive inhibition (Beach, 2005). Spinal ligaments may remain compromised for at least seven hours after unloading (LaBry, 2004). This may be due to micro-trauma and acute inflammation within the viscoelastic tissues, a process which has been documented within the supraspinatus ligament (Solomonow, 2003). Continued buildup of inflammatory mediators within the tissue may cause characteristic pain the following morning after sustained strain.

Injury is not associated with the magnitude of the load but the duration of the load (LaBry, 2004).

8. Incomplete recovery from fatigue

Cyclic loading allows for brief periods of partial recovery between each repetition of flexion hence the need for frequent breaks with prolonged sitting (Little, 2005). Studies have shown a reduced resistance to bending after one hour of submaximal lumbar flexion (Adams, 1996).

In one study using human volunteers, 20 minutes of deep flexion followed by a 25 minute rest period resulted in a 50% recovery, and a 50 minute rest period resulted in a 70% recovery from the resulting creep (McGill, 1992). This suggest that recovery rates are longer than expected, and possibly greater than 2 days (LaBry, 2004). These findings explain why sedentary desk jobs increase the risk of mechanical low back pain.

9. The osteoarthritis degenerative cascade

Osteoarthritis is considered a type of organ failure, where one injury to one component leads to damage of the other components. This collectively results in overall joint failure and the development of clinical manifestations of osteoarthritis (Peterfy, 2004). Alterations within the ligaments and their insertions can affect the adjacent bone and synovial tissues in the development of osteoarthritis (Fleming, 2005; McGonagle, 2010; Wheaton, 2011) at, for example, the knee and spine (see below)

Ligaments of the knee

Inflammatory proteins

The imbalance between the breakdown and repair of joint tissues in osteoarthritis is the result of inflammatory mediators, matrix components and mechanical stressors. Nuclear factor-kappa B and mitogen-activated protein kinase pathways play a predominant role in the expression of metalloproteinases and inflammatory genes and proteins that potential catabolism. (Berenbaum, 2011). The endogenous anabolic factors that stimulate bone and cartilage regeneration and remodeling are insulin-like growth factor one (IGF-1), transforming growth factor (TGF)-b and bone morphogenetic proteins (BMPs). (Fan, 2004; Lajeunesse, 2004)

The arthritic bumps on your fingers

Research conducted in the hand has found the collateral ligaments are the source of inflammatory degeneration and of the periarticular pattern of inflammation noted with osteoarthritis of the hand, with considerable degenerative changes near the ligamentous origins. (McGonagle, 2008; Tan, 2005; Tan, 2006). In early osteoarthritis, inflammatory tissue bulges through the joint capsules at characteristic points of weakness between the collateral ligaments and the extensor tendon. In chronic osteoarthritis, firm nodes form at the same site. The restraining effect of the collateral ligaments and the extensor tendons determine the characteristic clinical feature of generalized nodal osteoarthritis. The collateral ligaments influenced the location of both MRI‐determined bone edema and bone erosion in early osteoarthritis. These changes suggest that the interaction between the ligaments and fibrocartilage lead to the development of osteoarthritis. (Tan, 2006)

10. Medications that interrupt tissue repair

Opioids

Narcotics alter the neurological feedback responses of the body, and may also suppress immune system function (Roy, 1996). Opiates have the same action as cytokines and can modulate the immune response by interacting with central and peripheral nervous system receptors creating neuroinflammation, similar to an endotoxin, in the central nervous system (Wang, 2012). Potential mechanisms of this activity include effects on the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. Opioid receptors have also been identified in peripheral nerves and immune inflammatory cells (Vallejo, 2004). Morphine (a type of opioid) has also been found to prolong recovery from neuropathic pain in animal studies (Grace, 2016).

Anti-inflammatory drugs

Anti-inflammatory drugs are only mildly effective in relieving the symptoms of most ligament, tendon and muscle injuries and are potentially deleterious to soft tissue healing (Mehallo, 2006). They are not recommended for muscle injuries, bone (or stress) fractures, or chronic tendinopathy (Ziltener, 2010). A review noted that there was insufficient evidence of a detrimental effect in soft tissue healing when using NSAIDs at standard doses for ≤2 weeks. A limited number of studies demonstrated the impairment of soft tissue to bone healing (Chen, 2013). NSAIDs work by blocking cyclooxygenase enzymes, which convert arachidonic acid to prostaglandins that are involved in the healing response (Radi, 2005). They have been found to delay but not impair ligament healing (Warden, 2006). NSAID should be more carefully used in ligament injury, joint injury and osteoarthritis (Paoloni, 2009).

Corticosteroids

Corticosteroids are known to have inhibitory effects on glycosaminoglycans, proteins, and collagen synthesis (Hollander, 1974). The anti-inflammatory effect of corticosteroids can result in a decrease load to failure of a partially injured tendon (Kapetanos, 1982). Dexamethasone has been found to decrease cell number and collagen synthesis within tenocyte cultures in a concentration-dependent manner with direct effects on tenocyte proliferation and collagen accumulation (Scutt, 2006).

A recap of the 10 secrets you need to know to keep your ligaments healthy:

Ligaments, not muscles, control how forces go through your joint and keep your joints healthy in many different positions.

Ligaments have immense strength; do not stretch them out too far or for too long.

Ligaments do not always heal.

Repetitive strain injuries develop over many years, then appear one day and for no apparent reason.

United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), Third Edition, 2014. Rosemont, IL. Available at http://www.boneandjointburden.org. Accessed on November 20, 2015.

An MRI can be very easy to understand if you know where to look and radiologists who do this for a living make it look very easy. This is a very simple guide to help you understand your MRI pictures and how they correlate with your symptoms.

I will start with the length-wise sagittal views, or what I call the baguette views as they are easier to follow. Then I will review the axial or cross-section views that I call the sliced bread view.

1. Central canal

Start with the lengthwise image (sagittal images) and look at the middle of the central canal where the nerves float in the protective cerebral spinal fluid. Make sure you look at the picture where the central canal is white as it highlights as well as borders the structures that we are interested in such as the bones, ligaments and nerves of the spine. Anything that encroaches into the smooth linear central canal can be a potential problem such as the figure on the right which demonstrates severe spinal stenosis of the central canal.

2. Vertebral body

Next look at the 5 vertebral bodies that stack up and form the lumbar spine or the spine within the lower back. They are numbered top down from one to five. Their function is to support and protect the delicate nerves that pass through to the pelvis and lower legs. They should have a general square shape. If they look triangular, it indicates a fracture (inset).

3. Alignment

Look at the alignment of the posterior borders of the five vertebral bodies (red line). The picture on the left demonstrates a normal spine with a smooth line connecting the posterior borders. Any irregularity of that line by the vertebral bodies as demonstrated in the pictures on right represents excessive bone, ligament or disc wear-and-tear in the segment which causes greater motion and instability. This is called spondylolisthesis. This instability places greater stress on the discs which makes them degenerate faster resulting in a greater risk of disc herniation, nerve irritation, arthritis and pain.

4. Intervertebral Discs

Look between the vertebral bodies for the intervertebral discs. They are numbered from L1-2 to L5-S1 based on their location between the vertebral bodies. Discs have a great deal of fluid within them which allow them to act as shock absorbers but over time the discs can begin to dry out and degenerate.

5. Disc degeneration

A normal intervertebral disc has significant white signal internally (figure A) which represents normal fluid. As the intervertebral disc degenerates, the normal white signal is lost (figure B). Without the fluid, the disc begins to narrow and degenerate further (figure C). With loss of the interior supporting fluid, the thick collagen walls of the disc begin to bulge outwards into the central canal from the excessive pressure (figure D). The excessive pressure continues until the disc wall tears open and the remaining fluid within the disc squeezes out into the central canal (figure E). If a little material squeezes out it can result in a mild disc herniation. If a great deal of fluid squeezes out it is called a disc extrusion which can migrate (figure F). Basically the more material that is squeezed into the central canal, the greater the chance of severe pain, weakness, numbness and tingling.

6. Nerves

On both sides of the spinal column; you will find narrow keyhole-shaped canals called foramen. The foramen allow individual nerves to exit from the spine. Since the foramen are narrower than the larger central canal, a small disc herniation is more likely to pinch or irritate a nerve.

7. Axial views

The axial images or sliced bread views provide a clearer picture of a specific intervertebral disc and the adjacent nerves. A normal disc (figure A) provides ample room for the nerves to pass through. Any type of disc herniation (figure B) narrows the normally roomy canals causing the transiting nerves to become irritated or compressed which results in symptoms. A small disc herniation (figure C) may not produce any symptoms but a large disc herniation (figure D) may result in severe pain, weakness, numbness or tingling.

8. Spinal stenosis

The normal central canal is usually quite big (figure A) and houses and protects the descending nerves. Narrowing of the central canal is known as spinal stenosis (figure B). The condition occurs when the intervertebral disc (figure C), ligamentum flavum (figure D) and facet joints (figure E) undergo extensive wear-in-tear and degenerate. As they degenerate, they expand into and narrow the central canal which results in nerve compression. The resulting nerve compression can cause progressive pain, weakness and numbness.

Sitting all day is hard on your body. Most people believe it can increase your risk for back pain, but few people realize that it can also increase your chance of developing heart disease, diabetes and dying early. You want to break up your activity throughout the day alternating between standing with periodic sitting. Unfortunately, regular intense exercise will not help you recover from the negative effects of prolonged sitting. I should know as I was co-director of the Spine Center at NewYork-Presbyterian Hospital and I was also developing medical problems until I changed my relationship with my chair.

The cycle of sitting

People tend to fidget while sitting after several minutes, changing their posture until there is no remaining comfortable posture, at which point they get up. When you first sit on a chair, you tend to recline on the back rest. Over time you develop a slouch and sit on your sacral bone at the bottom of the spine instead of the ischial tuberosities or “sit bones”. This results in a c-shaped spine which is uncomfortable and also compresses the lungs, stomach and intestines. This posture also puts an additional strain on the discs, muscles and ligaments of your spine. When the strain becomes intolerable, you will then perch on the edge of the chair but this quickly becomes fatiguing so you will scoot back in the seat and use the back support again. Eventually you will slide down and restart the whole cycle over again until you are so uncomfortable that you stand up. The muscles of your spine never relax at any point during this entire cycle as you never encounter a stable position. Eventually you will need to stand or lie down to fully relax the muscles of the spine. This process makes it virtually impossible to design the perfect office chair. Zero-gravity type recliners are the closest chair that provides stable support, but it is difficult to use in an office setting.

With quiet standing, studies have shown that the only muscles that are active are the calf muscles so it is a position of relaxation of the spinal muscles as is lying down. With active standing there is constant muscle activity which is important for overall health. Your weight should be distributed though the bones and not the flesh (Cranz, 1998), as the bones can take a compressive load whereas the muscles and ligaments begin to fatigue with long periods of inactivity.

Sitting is hard work because chairs inhibit our usual comfortable movements when instead they should accommodate our movement so commonplace seating surfaces have become a major unaddressed health problem. With prolonged sitting in modern developed countries, we have lost the flexibility required to squat comfortably which some researchers believe it is a more comfortable work position (Cranz, 1998).

In early 20th century it was thought that the ankles had to have support, in the same way that we think we need a back support today (Cranz, 1998).

The modern office space

Robert Propst at Herman Miller wanted to design the perfect office in 1958. His goal was to improve the efficiency of the office by removing every motion or wasted second and to encourage chance encounters which are thought to fuel creativity. He believed in a porous work space with plenty of places for impromptu meetings. He called his creation the “Action Office”.

Propst reviewed the medical studies and insurance data at the time which confirmed that sitting was not a healthy activity so he also designed standing desks but they never caught on with his clients. He invented the standing desk which was an offshoot of clerks desks in the 1800s but people were more interested in sitting (Engelhart, 2014).

The renewed interest in office ergonomics is a return to the past when most office workers stood and sitting was considered lazy (Lohr, 2012). Michelangelo, Winston Churchill, Benjamin Franklin, Vladimir Nabokov and Ernest Hemingway stood. Leonardo da Vinci used a standing desk and Thomas Jefferson designed his own (Bennett, 2012) People have begun to realize there is a sitting crisis or “sitting disease” and the global health implications are enormous. It is not considered a niche market anymore although when I speak to patients, they are usually surprised by my suggestion that their office chair is causing spine or other medical problems.

Technology companies such as Google, Facebook , and Twitter have been ahead of the trend giving their employees ready access to adjustable standing workstations. The office furniture maker Steelcase has found sales of its stand-up desks are growing faster than for their conventional desks (Bennett, 2012).

During the workday, you may feel very active, but stop and think about your daily activities. For most people, movement is for shifting from one seat to another; from the car to work to home which is repeated day after day making the citizens of the developed world the most sedentary humans in the history of the world. You may spend 12 hours a day seated with an additional seven hours of sleeping which equals 19 hours of sedentary activity. Yet our bodies need constant, nearly imperceptible muscle activity to maintain normal function (Calorie, 2013), so regular exercise several times a week may not be enough.

Steve Bordley of Scottsdale, Arizona had a leg injury and could not run, so he walked slowly on a treadmill adjacent to his desk. He was shocked after six weeks when he realized that he lost 25 lbs and resolved his lingering back pain. This realization drove him to start a standing desk company called TrekDesk.

Productivity

Financial gains due to increased productivity and decreased absenteeism could offset the costs of an adjustable standing desk, but are realized over the longer-term, so this is not a justification for many organizations to replace the sedentary office environment (Mackenzie, 2015).

Research demonstrates decreased productivity with uninterrupted standing and the same may be true for uninterrupted sitting. In 2014, Dan Kois a writer for New York Magazine decided to live for one month without sitting which required novel approaches to normal activities such as driving and he found the whole process very disrupting (Kois, 2014).

The landmark study that surprised everyone

The London Transport Worker’s Study was the ground breaking study demonstrating the dangers of sitting. It was published in 1953 by medical journal Lancet and initially, the study was met with disbelief because no one thought exercise could keep people from dying. Even the authors of the study delayed publication for several years allowing experts to review the results before publication. The study demonstrated that bus conductors who walked around the bus had about half the risk of developing heart disease compared with bus drivers who sat all day (Morris, 1953).

Specifically, the conductors ascended and descended 500 to 750 steps per work day and were half as likely as the drivers to die of a sudden heart attack. Postmen also had lower cardiac disease than postal clerks who sat behind the counter.

The study also found that men who reported energetic regular aerobic exercise with sustained rhythmic dynamic contraction and relaxation of large muscles such as with cycling, swimming, fast walking, and jogging demonstrated lower coronary heart disease incidence than comparable men reporting equally energetic and frequent heavy work in the garden, in and around the house, or on the car (Paffenbarger, 2001).

The study suggests that the human body was made to remain active. Dr. Morris foresaw the rise of coronary artery disease due to the lack of exercise, smoking and poor diets in the western world even in the days before the proliferation of computers. When he saw the results of the study, he stopped smoking and started running for 20 min in the 1960s. At the time, people thought he was crazy.

In that era, lighting of cigarettes was considered exercise. Dr. Morris lived to nearly 100 and died in 2009. He thought that exercise was universal to health.

Humans need vigorous exercise to protect them from cardiac disease and he advocated public exercise facilities as the cheapest solution for the rapid ascent of coronary artery disease but to no avail (Kuper, 2009).

Research shows sitting is a risk factor for disease and premature death

According to the World Health Organization, physical inactivity is the 4th leading risk factor for death worldwide. Your body needs constant low level activity which is promoted by standing.

Minimal energy use is considered different than too little exercise. TV watching is the worst sedentary behavior imaginable, even worse than sitting while typing on a computer. This is due to the fact that your metabolic rate may go below your normal level compounded with commercials that promote unhealthy eating behaviors (Owen, 2012). Compare this energy expenditure with a hunter-gatherer who was constantly active. To match the energy expenditure of a hunter-gatherer would require you to walk an extra 19km per day.

One small study found on average that for every single hour of TV viewed after the age of 25, the viewer’s life expectancy was reduced by 21.8 (95% UI: 0.3-44.7) minutes (Veerman, 2012).

A person who works out at the gym is still in danger or coronary artery disease if they are inactive for the remainder of the day, even with serious strengthening exercise and cardio training.

Michael Perko, a professor at UNC-Greensboro believes that if you sit 6 or more hours a day, the health benefits of exercise are eliminated.

“Exercise is not the perfect antidote for sitting,” says Marc Hamilton, an inactivity researcher at the Pennington Biomedical Research Center.

Alpa Patel, an epidemiologist at the American Cancer Society, tracked the health of 123,000 Americans between 1992 and 2006. Men who sat six or more hours had a 20% higher risk of death compared to men who sat for three hours or less. The death rate for women who sat 6+ hours was 40% higher (Patel, 2010).

David Dunstan PhD Head of the Physical Activity laboratory at the Baker IDI Heart and Diabetes Institute in Melbourne found the risk of dying from cardiovascular disease rose by 11 percent for each additional hour of television a person sat and watched per day (Dunstan, 2010)

Simply breaking up prolonged periods of sitting with two minutes of walking every 20 minutes made a big difference (Dunstan, 2012).

Christine Friedenreich, a University of Calgary cancer epidemiologist noted in 2010 that sitting was associated with a higher risk of colorectal, endometrial, ovarian and prostate cancer, as well as cancer mortality in women (Friedenreich, 2010)

One study suggests that if you sit for more than 11 hours a day, you will have a 40% percent greater risk of dying in the next three years. (Ploeg, 2012)(Glatter, 2013), but no link has been found between standing and premature death (Katzmarzyk, 2014).

James Levine, a researcher at the Mayo Clinic in Rochester, Minn. focuses his research activities on inactivity. He believes excessive sitting is lethal. Overall in his studies, people who do not gain weight were consciously active, a concept he describes as “NEAT”, which stands for Non-Exercise Activity Thermogenesis. He feels that it is a war against inertia itself, which sickens the mind as well as the body (Vlahos, 2011).

People who walked around for as little as 2 minutes decreased their risk of mortality by 33% compared to people who sat nonstop probably due to weight loss and other metabolic changes (Beddhu, 2015).

The amount of sitting we do in a day outweighs any benefits we get from exercise. Sedentary behaviors can lead to death in cardiovascular disease and cancer as well as increase your risk of diabetes sitting for more than 12 hours a day increase the risk of type II diabetes and 90% (Biswas, 2015).

Kimberly A Reich PhD in the Muscle Biology and Imaging Laboratory, Department of Kinesiology, University of Massachusetts, Amherst found changes in gene expression following 24 hours of inactivity and her team is not sure if these changes are reversible (Reich, 2010).

Telomeres were found to lengthen in those who sat the least in a sense allowing cells to become younger with no correlation based on the amount of exercise that was done, in comparison to those who sat who were found to have shorter telomeres (Sjogren, 2014).

A search of the medical literature in Pubmed.com for prolonged sitting and back pain did not provide any studies concluding that prolonged sitting results in back pain. In observational studies, back pain is thought to be due to lifting, bending and prolonged sitting (Stevens, 2015) or even prolonged sitting and standing, weakness in the legs, regular exercise, and smoking (Bener, 2014) as well as obesity.

Your body is made to move

The general concept is fairly simple. When you sit for long periods of time, your body will work to maximize its efficiency. Part of this process is to deactivate muscles that are not used. In this case it is the large muscles in the legs. This causes about one third of your overall muscle mass to go offline resulting in the accumulation of sugar and fat in the bloodstream. This results in the clogging up of your finely tuned machine. Over time this raises your overall cholesterol (decreased lipoprotein lipase) and blood sugar increasing your risk of developing coronary artery disease and diabetes. Enzymes that burn fat decrease by 90% after an hour of sitting.

This also decreases your metabolic rate to about 1 cal burned per minute or a third of what it would be if you walked around.

Decreased physical activity has been found to activate the genes that promote the development of inflammation, diabetes and cardiovascular disease. Standing activates muscles so excess blood glucose is quickly absorbed by the muscles instead of accumulating in the arteries and veins (Thyfault, 2015).

Even simple activates such as fidgeting can have a protective effect. There was increased mortality seen in the group that reported the lowest level of fidgeting. Some people feel that squirming around is the body’s way of dealing with a transition from super-active lifestyles, such as hunting and gathering by the cavemen to modern sloth-like behavior (Think Jabba the Hutt in Star Wars) (Feltman, 2015).

In children a similar effect happens although children can recover faster. One study by Ali McManus PhD, an associate professor of pediatric exercise physiology at the University of British Columbia in Kelowna found that after a single session of prolonged inactivity for 3 hours, the children developed changes in their blood flow and arteries that in adults would suggest cardiovascular problems. Dr. McManus noted that chairs were as alluring to the young girls as they are to grown-ups and that they were content with movies or an iPad (McManus, 2015; Reynolds, 2015).

In response to the need for children to move, one elementary school in Virginia is trialing pedal desks (Hurford, 2015). Some people feel that a child’s need to move is a normal physiological response to the restrictive nature of a chair and possibly by keeping their muscles moving, children may do better in school.

Varicose veins are common in people who sit, but uncommon in cultures where people sit on the ground (Cranz, 1998).

John Buckley, a professor of applied exercise science at the University of Chester has commented on the reduction in the risk of developing key chronic diseases in people who stand for more than 2 hours per day.

Some people feel that their arthritis pain actually decreased

Standing burns one half to one calorie more a minute than sitting. In an eight hour work day that equals 480 additional calories consumed. Sitting more than an hour lowers the levels of the enzyme lipoprotein lipase, which causes calories to be sent to fat stores rather than to muscle, Dr. Hedge said (Reddy, 2015).

Over the course of a year you burn an extra 30,000 calories or 8 lbs per year. This is equivalent to running over 8 marathons per year just by standing for 3-4 hours a day at work (Calorie, 2013).

Top 10 activities to keep you healthy at your computer

To remain active during the day, consider using an adjustable standing desk with periodic breaks of walking and sitting.

Ask your employer for an adjustable standing desk. Denmark employers are required by law to provide their employees with adjustable desks

Consider a Treadmill desk. Although they may lower general productivity they can break up the daily routine and keep you moving.

For every 30 minutes of sitting, you should stand for 8 minutes and stretch for 2 minutes according to Alan Hedge PhD, an ergonomics professor at Cornell University or consider even two minutes of walking every 20 minutes.

To decrease the pressure on your legs while standing, consider raising one foot on a raised surface or block to allow you to bend your hips and alternately as needed from Jack Callaghan PhD of the University of Waterloo and Don Meredith, a writer (Meredith, 2013)

Consider including regular aerobic exercise such as cycling, swimming, fast walking, and jogging to keep your muscles in good working order.

Good posture allows you to feel relaxed and allows you to distribute your weight evenly to the bones decreasing the stress on your muscles, joints, tendons, ligaments.

Do not let the siren call of dropping your head forward towards the computer screen happen.

Remember adjustable office desks and chairs come in different sizes and they should be fit appropriately to your frame. Choosing the rich chair can be a very time consuming process as expertly described by Tim Ferris.

Proper sitting posture (When you have to sit)

Keep hands, wrists and forearms in line as well as parallel to the floor

Keep your chin parallel to the floor and in line with your torso

Keep your shoulders relaxed with your arms by your side

Keep your elbows close to your body bent approximately 90°

Keep your feet flat on the floor and if your feet are dangling, use a support to allow your feet to remain flat

Keep your thighs parallel to the floor

Keep your knees and hips at approximate 90° of flexion

Innovative Ideas

Consider “Tiny Habits” by BJ Fogg which may allow you to change the small factors in your life that are contributing to your general health. BJ Fogg is a behavior researcher at Stanford who studies how small factors can have a large influence. For example, arising from your chair every hour gives your back a break and allows you to feel looser at the end of the day. (Schulte, 2015)